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Objective: Described here is a simple treatment for female urinary incontinence present and concurrent cystocele repair, if present. The objective of this technique which combines a bladder neck and a suprapubic percutaneous suspension, is to obtain by a sling effect, efficient cure of the urinary incontinence, in avoiding the common retention problem., Patients and Methods: Between 1992 and 1998, 49 black female patients were treated with this procedure. Average age was 18 years old (the youngest 14, eldest 29 years old) 39 were primigravid while 10 were multigravid (2 to 6 childbirths). 12 (24. 4%) have undergone at least 2 operations for fistula cure, 6 of the patients showed previous incontinence surgery; Burch technique (n=1), Martius fat sling (n=3) and anterior colporraphy (n=2). 25 patients (51%) were suffering from a severe incontinence, for 17 cases the urine leak was grade 2 and 8 cases grade 3 at decubitus., Results: No bladder lesion occurred on any of the 49 patients. Except for one general peritonitis which occurred on a patient who was receiving a combined recto-vaginal fistula operation, the post operative complications were minor (n =7). We observed only one direct recurrent urinary incontinence which was treated a second time with the same technique and was cured. For 46 studied cases and an average follow-up of 28.6 months, 29 patients (63%) were declared totally cured, 8 (17.3%) showed functional improvement, 9 (19.5%) remained incontinent. The global success rate (cure and improvement) was obtained in 80% of cases. The results were less satisfactory in multi-operated patients, particularly in those who suffered from extensive cervico urethral damage (Group III). In this group only one out of two patients obtained cure or improvement., Conclusion: Due to its real simplicity the bladder neck and vagina wall sling is easy to redo, and because its reliability we have chosen this procedure as a choice treatment for incontinence following a vesico vaginal fistula. The excellent results confirmed by a longer follow-up has led us to extend its indication to all types of female urinary incontinence. This technique is particularly well suited for use in developing countries.

Destruction of the urethra is the most severe complication of pregnancy-related vesicovaginal fistula. Although uncommon in Europe, pregnancy-related urethral destruction is still observed in Africa. In this study we describe our experience with a new reconstruction technique using a pedunculated skin flap raised from the labia majora. Between January 1992 and June 1996 we treated 35 patients in the Urology Department of Niamey Hospital in Niger. All patients were black. Mean age was 18 years and mean follow-up was 19 months. Two plasty techniques were used, i.e. extension (16 cases) and tubulisation (19 cases). Urinary incontinence was treated using a suburethral loop system created using a fatty flap taken from the labia majora (Martius method). Urethrocervico-suspension of the vagina was necessary in 6 cases. Normal micturition with no leakage was obtained in 24 patients (68.6%) and functional improvement in 6 cases (17.1%) Treatment failed in 5 cases (4.2%). In comparison with previously reported techniques, urethral reconstruction using a pedunculated labial flap and suburethral looping system allows successful treatment of pregnancy-related urethral destruction in 70% of cases. This technique is particularly well suited for use in developing countries where occurrence of this complication is most frequent. However even with the greatest skill, creation of a physiologically perfect closure system is currently impossible.

A homogeneous series of 261 post-partum urogenital fistulae treated over the last ten years in Africa by the same operator is analysed. Mostly occurring in young, primiparous women in a rural environment, the predominant cause was neglected dystocic delivery in the bush (65.5%). The fistula was traumatic in 27.9% of cases and secondary to hysterectomy in 6.8%. 247 patients underwent surgical repair. The choice of repair procedure, generally performed via the transvaginal route (92.3%), was based on the anatomical classification of the various lesions into three groups of indications: Group I: simple fistulae (98), in which surgical treatment consisted of closing the fistula orifice by simple separate suture of the bladder and vagina, generally followed by success. Group II: more difficult fistulae (109) with severe tissue damage, raising the dual problem of continence and healing and requiring the use of mattressing with a well vascularised adjacent tissue (55 cases). Group III: complicated fistulae (54) with the presence of associated lesions, often requiring multiple urological, genital and intestinal operations as well as complementary plastic techniques (31 cases): double autoplasty of the labia major (17) and adipocutaneous pedicle skin flap (14). 212 of the 261 patients (81.2%) were cured, 23 obtained partial cure (insufficient continence, amenorrhoea, vaginal sclerosis making sexual activity impossible) and there were 26 failures. Urinary diversion was the only solution in 14 patients (7.8%). The objective in surgical correction of urogenital fistulae is twofold: to obtain good quality cure (81.2%), i.e. controlled micturition and a normal, genital, conjugal and social life. overcome the limitations of palliative operations which are always poorly accepted in Africa, at the cost of repeated, staged surgery designed to simplify the lesions in the most severely damaged cases. Prevention programmes designed to eradicate urogenital fistulae, which constitutes a real public health problem in developing countries, will only be made credible by an improvement in the quality of the results obtained in the treatment of this disease.

The author reports 230 cases of vesico-vaginal fistula taken from a series of 271 obstetrical fistulae treated by the same operator. The fistula was obstetrical in most cases (93 percent), occurring in young women and primiparas. Associated lesions (urethro-vaginal, recto-vaginal and perineal) were observed in 23.4 percent of the patients. Also studied were 7 pure urethro-vaginal fistulae and 2 urethro-vesical fistulae. Surgical treatment, usually (85.6 percent) through the lower route, consisted of closing the orifice of the fistula by simple separate sutures performed on the bladder and the vagina (Chassar Moir) in 95 cases. A filler tissue, a muscular and fatty pedicle flap (Martius technique), was used in 55 cases. Complementary techniques were considered indispensable in 49 cases. Eighteen patients underwent palliative surgery. Among 230 fistula patients whose postoperative follow-up ranged from 6 months to 1 year, 180 (80 percent) were considered cured (no incontinence and recovery of mictional function), and 17 were considered partially cured (sphincteral leakage during efforts); there were 29 failures. Far from being eradicated in Africa, vesico-vaginal fistulae continue to be one of the major public health problems, with an average annual prevalence of 2 percent. This critical situation is due to different social, economic, traditional and cultural factors which stay firmly inalterable. There is a need for a fistula management strategy based on a classification of the lesions encountered to increase the chances of success. The author describes the main prognostic and therapeutic groups: simple fistulae where success was obtained as a rule (group I, 33 percent of the cases in this series); difficult fistulae (group II, 43 percent), with the dual problem of attaining watertightness and healing, where the support of a well-vascularized filler tissue has proved necessary (Martius); complex fistulae (group III, 23.9 percent), where the associated lesions call for several urological, genital and gastrointestinal operations. Complete anatomical destruction of the urethra, accompanied by sclerous atresia of the genital tract, marks the limit of surgical possibilities of repair, beyond which palliative surgery has to be accepted.

The vesicovaginal fistulae encountered in Africa are a real plague. Their origin is obstetrical as a rule, and they occur in young women, often in primiparas. They are seldom simple as they have been operated repeatedly and involve associated lesions and a large loss of substance, so that they raise complex problems of repair. The experience with the treatment of 230 obstetrical fistulae by the same surgeon in Africa leads the author to describe a repair technique fit for complex fistulae, especially those involving an extensive loss of substance and associated lesions (rectovaginal fistula, perineal destruction). With a low approach, the procedure consists in using a filler tissue, namely a skin flap removed from a greater lip, for which the vasculature is maintained by the preservation of a thick musculous and fatty pedicle, cut from the fibers of the bulbocavernosus muscle. Once sutured around the orifice of the fistula, this graft closes it while fostering its healing. Out of the 14 patients treated with this technique, the results achieved were regarded as good for 10 (72%), including 7 after a first operation and 3 after second surgery. In 9 cases, there were associated lesions, including 5 rectovaginal fistulae and 4 cases of complete tearing of the perineum. We have had 4 failures, including 3 definitive ones, and a partial failure with the persistence of urine incontinence in station due to be destruction of the ureter. When the simpler Martius' procedure (on which ours is patterned) is no longer sufficient, the use of a pedicled skin-fat graft taken from the greater lip allows considerably restricting the indications of palliative surgery. Our technique increases the percentage of success for fistulae regarded as irreparable or after the usual repair procedures have failed.

Ten-year experience in Africa with post-delivery fistula therapy, including 39 cases of combined recto-vaginal lesions and 13 cases of laceration of perineum, prompted the author to describe a technique for surgical repair of vesico-rectovaginal fistulas. Inspired from Martius' graft of already proven efficacy in the treatment of complicated vesico-vaginal fistulas, the author used the same procedure on all complex cases of combined recto-vaginal fistulas, i.e., autoplasty of the labium majus. This operation carried out intravaginally consists in utilizing a flap of fatty tissue--either a split graft or one taken separately from each labium majus, placed in contact with the suture lines of the vesical and rectal walls. This dual autoplasty performed optimally in a single step, may however also be carried out separately whenever necessary. Over a period of 4 years (1985-1989), 17 female patients were operated on using this procedure. Treatment of both fistulas, vesico- and recto-vaginal, could be achieved in 11 cases during the same operation, and in 9 cases this involved using a single split graft. 14 women recovered, including 3 who had repeated surgery (2 bladder-derived Martius grafts and one dual autoplasty). The 3 failure cases all had repeated surgery and presented quite important lesions and tissue damage. Failure was considered final in two cases and partial in one case (residual orthostatic urinary incontinence). Dual autoplasty of the labium majus has provided cure to 14 out of 17 surgical patients in one or two operations, that is, 82% of cases, which is an excellent score considering the special difficulty of treatment encountered.

Experience in fistula repair of over 190 obstetrical fistulae in Africa, all done by the same operator, have led the authors to describe a technique adequate to repair complex fistulae with a large loss of material, associated with other damages (recto-vaginal fistula, and perineal damage). This operation conducted thru the vaginal route consiste in using a replacement tissue, the pedicle musclefat flap, thick, well vascularized together with a skin graft obtained from the major labia, this is then sutured around the fistuleus gap thus permitting its closure and activating the healing process. This technique was employed on 11 patients, 8 were successfully repaired, 5 of them, after the 1st operation while for 3 of them, the fistula was repaired after the 2nd operation. For 6 cases, other damages were present: 4 recto-vaginal fistulae, 2 cases with the perinea completely damaged. We have met 3 failures, 2 are definitive, where a palliative treatment was administered (uretero-ileo-sigmoidostomie, Bricker) and 1 is considered a partial failure due to the persisting urinary incontinence from urethra damage. Our operational technique, derived from the Martius is useful for such cases wherein the Martius would be insufficient. It increases the chances of successful repair for such fistulae normally considered incurable or after failure met by the use of usual methods of fistula repair. This technique is likewise valuable because it retards the necessity of going to the extremity, which is the palliative operation.